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dental practice July 2009
www.dental-practice.org
Making sense of dentine
hypersensitivity
CPD
David Gillam BA BDS MSc DDS FRSPH FHEA reviews the literature
D
ISCOMFORT from dentine sharp in character and short in identifying the various aetiological and There is certainly disagreement
hypersensitivity (DH) is a duration, although occasionally pain predisposing factors that may be between investigators regarding the
common finding within the persists as a dull ache or vague involved in the exposure of dentine. importance of plaque control in the
adult population. sensation on the affected tooth. For example, the development of a development of the condition that has
Previous epidemiological studies Sensation from cold stimuli appears to hypersensitive lesion may be as the led some investigators to suggest that
(questionnaire and clinical) have be the most common complaint. result of two processes, namely lesion there may be two distinct aetiologies
indicated four to 69 per cent of the localisation and lesion initiation (Addy, 2002).
populations studied experienced some Aetiology and (Dababneh et al, 1999). For example, those patients who
degree of discomfort from DH (Gillam predisposing features Recession as a result of abrasion may have relatively healthy mouths and DH
and Orchardson, 2006) although this The aetiology of the condition is therefore dictate the localisation of a as a result of meticulous and perhaps
figure is somewhat reduced following multi-factorial and not completely lesion whereas sensitivity may arise overzealous oral hygiene with those
clinical examination (Orchardson, understood, although it has been only when erosive factors expose the who complain of DH as a result of
1995). demonstrated that the structure of dentine tubule openings by removal of periodontal disease and/or its
Females appear to suffer more than dentine in the affected areas is altered, the smear layer covering the dentine treatment.
males, presumably due to their overall containing a larger number of patent surface (Addy, 2005). It is generally recognised that those
healthcare and better oral hygiene dentine tubules than unaffected areas Erosion (acid dissolution) occurs due individuals with diagnosed periodontal
awareness. Prevalence of the condition (Absi et al,1987). to an excessively acidic environment in disease and having periodontal therapy
appears to peak at the end of the third Yoshiyama et al (1989, 1990, 1994) the mouth. Sources of acid may be including scaling procedures may
decade and the beginning of the fourth reported that a greater proportion of occupational, medicinal, due to illness Continued on page 12
(Addy et al, 1985). the tubules were patent in the sensitive (bulimia, gastric
From the published literature, it is areas and also the presence of tubule- regurgitation) or
apparent that some dental like structures situated superficially acidic diet (eg
professionals appear confused about beneath the surface of sensitive carbonated drinks,
the diagnosis, aetiology, mechanisms dentine. fruit). More recently
and clinical management of DH Not all exposed dentine, however, is the term abfraction
(Schuurs et al, 1995; Gillam et al, 2002; sensitive; evidence from SEM has been added to
Canadian Consensus document, 2003; investigation of extracted teeth would the list of factors.
Orchardson and Gillam, 2006). suggest that there are differences It has been
Evidence from these studies would between “sensitive” and “non- suggested that all
also appear to suggest that there is not sensitive” dentine in that there are these mechanisms
only a communication gap between more open dentinal tubules (with a alone or in
dental professionals and their patients greater mean orifice diameter) in combination may
in the reporting and subsequent “sensitive dentine” (Absi et al,1987). induce removal of
diagnosis and treatment of DH, but These findings appear to be the enamel and
also an apparent lack of awareness consistent with Brännström’s (1963) expose the
among dental professionals of the “Hydrodynamic Theory” of stimulus underlying dentine
importance of implementing transmission across dentine. This (see reviews by Addy
prevention strategies to eliminate the theory proposes that minute rapid and Dowell, 1983;
aetiological causes of DH. shifts (in either direction) of the fluid Chabanski and
It is also important to note that the within the dentine tubules (following Gillam, 1997).
number of patients who perceive DH stimulus application) may result in
to cause serious pain may still present a activation of the sensory nerves in the Clinical
significant clinical challenge for the pulp/inner dentine region of the tooth. features
dental practitioner. This paper aims to Currently there are two main Most reviews have
provide an overview of the condition approaches for the treatment of DH indicated that the
and provide dental professionals with based on the Hydrodynamic Theory, teeth commonly
information that they can use in the namely: (1) tubule occlusion and (2) affected are the
Note 1. Pain evoked by thermal, evaporative (jet of air), probe, osmotic or
diagnosis and clinical management of blocking nerve activity through direct canine and premolar
chemical stimuli.
Note 2. Alternative causes of tooth pain include caries, chipped teeth, cracked
this troublesome and enigmatic ionic diffusion (increased potassium with the buccal
tooth syndrome, fractured or leaking restorations, gingivitis, palatogingival
condition in their practice. ions concentration acting on the pulpal aspect of the tooth
grooves, post-restoration sensitivity or pulpitis.
According to Addy et al (1985) and a sensory nerve activity) (Ling and more frequently Note 3. Treatment may be delivered in a stratified manner, as follows: with
Canadian Consensus document (2003), Gillam, 1996). exposed as a result
localised or severe DH, practitioners may prefer to treat the patient directly,
dentine hypersensitivity is “pain According to Gillam and of excessive and/or
using an in-office procedure.
Note 4. Some form of follow-up is recommended. However, the follow-up
derived from exposed dentine in Orchardson (2006), a number of incorrect tooth
interval may vary, depending on patient’s or practitioner’s preference and
response to chemical, thermal tactile or reviews (Dowell et al, 1985; Krauser, brushing in
circumstances.
osmotic stimuli which cannot be 1986; Irwin, 1988; Addy and West, association with Note 5. If mild sensitivity persists at the initial follow-up appointment,
explained as arising from any other 1994; Chabanski and Gillam, 1997) other aetiological
the practitioner may continue with preventive and at-home therapies. If the
dental defect or disease”. over the last 20 years have provided a factors (Addy et al,
sensitivity is more severe, some form of in-office treatment may be appropriate.
[Gillam DG, Orchardson R. Advances in the treatment of root dentine
Patients generally complain that pain degree of information that may be 1985; Orchardson
sensitivity: mechanisms and treatment principles. Endodontic Topics
arising from DH is rapid in onset, helpful to the dental professional in and Collins, 1987).
2006; 13: 13-33.]
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DP July 09 8, 10, 12-20, 22.indd10 10 24/6/09 13:05:13
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